This week in Medicare updates

HIM-HIPAA Insider, July 20, 2015

CMS and AMA announce efforts to ease transition to ICD-10 for providers

On July 6, CMS posted a press release announcing efforts to continue to help physicians get ready ahead of the October 1 deadline for ICD-10 implementation. In response to requests from the provider community, CMS stated it is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD- 10 code set.

On July 8, CMS posted a proposed rule that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (MPFS) on or after January 1, 2016. This year, CMS is proposing a number of new policies, including several that are a result of recently enacted legislation. The rule also finalizes changes to several of the quality reporting initiatives that are associated with MPFS payments, including the Physician Quality Reporting System, the Physician Value-Based Payment Modifier, and the Medicare EHR Incentive Program, as well as changes to the Physician Compare website on Medicare.gov.

CMS posted the end-stage renal disease prospective payment system (ESRD PPS) proposed rule in the Federal Register July 1. It is to update and make revisions to ESRD PPS for calendar year (CY) 2016. The proposals in this rule are necessary to ensure ESRD facilities receive accurate Medicare payment amounts for furnishing outpatient maintenance dialysis treatments. This rule also proposes to set forth requirements for the ESRD Quality Incentive Program (QIP) for CY 2016. In an effort to incentivize ongoing quality improvement among eligible providers, the ESRD QIP proposes to establish and revise requirements for quality reporting and measurement, including new quality measures for payment year 2019 and beyond, and updates to programmatic policies for payment years 2017 and 2018.

OIG releases report on drugs commonly used by dual-eligible beneficiaries

The OIG posted a memorandum July 1 to fulfill the annual reporting mandate from the Patient Protection and Affordable Care Act (ACA) for 2015. The ACA requires the OIG conduct a study of the extent to which formularies used by stand-alone prescription drug plans and Medicare Advantage prescription drug plans (referred to jointly as Part D plans) under Medicare Part D include drugs commonly used by full-benefit dual-eligible individuals (i.e., individuals who are eligible for both Medicare and full Medicaid benefits).

The OIG posted a report July 1 detailing a study in which it used skilled nursing facility (SNF) claims to analyze billing for changes in therapy from fiscal years 2010 through 2013. The OIG also determined whether, under the new policies, SNFs used assessments differently when decreasing therapy than when increasing it. Lastly, OIG determined the extent to which SNFs used the new assessments incorrectly.

On July 2, CMS rescinded Transmittal 1481, dated March 27, 2015, and replaced it with Transmittal 1517 to remove the requirement for report files to be password protected and clarify how files shall be sent to CMS. All other information remains the same. The original transmittal requires Medicare Administrative Contractors to produce a report for each tester that provides the final status of each claim that was submitted.

On July 2, CMS released a change request to modify the current version of Pub. 100-04, Medicare Claims Processing Manual, Chapter 22-Remittance Advice to remove outdated information. Additional clarification of instruction has been added to this chapter.

On July 2, CMS rescinded Transmittal 3286, dated June 26, 2015, and replaced it with Transmittal 3289 to correct a typo in the business requirements; “FY 2015” was corrected to read “FY 2016.” All other information remains the same.

On July 6, the OIG posted a report stating Wisconsin Physicians Service Insurance Corporation—a Medicare contractor for Iowa, Kansas, Missouri, and Nebraska—overpaid a provider that incorrectly billed for Aflibercept by $432,000.

CMS posted a proposed rule in the Federal Register regarding a new Comprehensive Care for Joint Replacement model meant to address the fragmentation present in the current system when a beneficiary requires a joint replacement by focusing on coordinated, patient-centered care. This model aims to improve the care experience for the many and growing numbers of Medicare beneficiaries who receive joint replacements and places the patient’s successful surgery and recovery as the top priority of the healthcare system.

CMS posted a final decision memorandum July 9 stating there is sufficient evidence to add periodic human papillomavirus (HPV) testing as a benefit for certain Medicare beneficiaries. HPV testing would be covered once every five years as an additional preventive service for asymptomatic beneficiaries aged 30 to 65 years in conjunction with the Pap smear test. CMS will cover screening for cervical cancer with the appropriate FDA approved/cleared laboratory tests, used consistent with FDA approved labeling, and in compliance with Clinical Laboratory Improvement Amendment regulations.

CMS posted a proposed rule July 10 in the Federal Register that would update home health prospective payment system (HH PPS) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply conversion factor. This would be effective for episodes ending on or after January 1, 2016. The rule proposes reductions to the national, standardized 60-day episode payment rate in calendar years 2016 and 2017 of 1.72% in each year to account for estimated case-mix growth unrelated to increases in patient acuity. The rule also seeks to create a home health value-based purchasing model in which all Medicare-certified home health agencies in selected states will be required to participate. The rule also proposed changes to the home health quality reporting program requirements and updates the HH PPS case-mix weights. Comments are due by September 4.

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